Passport renewal at Putrajaya

Passport renewal is now so easy. Just go to the new office at presint 15, bangunan chancery place, jalan diplomatik 2/2. Proceed to groundfloor, turn left and you will see an entrance on the left to a room where thr KiPPas kiosk is. You will need a photocopy of your ic, old passport and rm300 for a 5 year renewal. Insert your passport and ic into the slots and follow the instructions including paying rm300 cash. You will not need to insert photo and ic copy into machine. At the end after payment, get the receipt and proceed to the small desk beside the kiosk which is manned by an officer. Give her the receipt, a copy of the passport photo, a copy of your ic and your old passport. She will give you a number. Do not fret if you forgot to photostat your ic and do not have a photo. beside the kiosk there is a counter to photostat and take your photo. 30cents for ic photostat. photo rm15.
Proceed then out of this room, turn left and you will see sign boards directing to the main office for passport about 10metres away. Wait for your number to be called, ususally about an hour. When your number is called, sign your passpsort and the form, and lo behold, your new passport is in your hands.

Problems of a large prostate

AGE WELL
By Assoc Prof Dr CHRISTOPHER C.K. HO

Aside from urinary problems, benign prostate hyperplasia can also affect a man’s sex life.

BENIGN prostate hyperplasia (BPH) is a common condition seen in middle-aged and elderly men. It is an enlargement of the prostate gland, which — although not cancerous — may cause problems, as it may impede the flow of urine out of the bladder.

It may also cause bleeding during urination, and predispose to infection of the urine.

If urine is totally obstructed from passing out of the bladder, it will cause a build-up of pressure and urine in the bladder, which when severe, may cause back-pressure, as well as reflux of urine into the kidney. This will eventually cause renal failure.

BPH and sex

Aside from all the problems described above, BPH may also affect a man’s sexual life.

Multiple studies have shown that BPH and sexual dysfunction are inter-related.

Sexual dysfunction refers to sexual problems, such as erectile dysfunction (unable to maintain satisfactory erection of the penis for sexual intercourse), ejaculatory dysfunction (failure to expel semen), and low sexual desire.

BPH has been found to be a risk factor for erectile dysfunction, independent of age.

BPH has also been found to be a stronger predictor of sexual dysfunction compared to diabetes, heart disease or hypertension. In fact, erectile function has been shown to deteriorate in tandem with worsening symptoms of BPH.

How does BPH cause worsening of sexual function?

There are a few theories, which include the nitric oxide/cyclic guanosine monophosphate pathway, rhokinase, overactivity of the autonomic pathway, and pelvic organ atherosclerosis.

All these theories have one thing in common — failure of relaxation of the smooth muscle.

Relaxation of the smooth muscle in the erectile tissue of the penis is needed for engorgement of the penis with blood.

Similarly, relaxation of the smooth muscle in the prostate and bladder neck is needed for urine to pass out of the bladder through the penis.

When there is failure of relaxation of the smooth muscle in the penis, this leads to erection difficulties; while in the prostate and bladder neck, urination difficulties occur.

Treating BPH

Treatment of BPH consists of medical, as well as surgical interventions.

So, does treating BPH improve the symptoms of BPH?

It depends on the medication given. There are basically two groups of medication for BPH, ie alpha blockers and the 5α reductase inhibitors.

Examples of alpha blockers include terazosin, doxazosin, alfuzosin, tamsulosin and silodosin.

There are only two types of 5α reductase inhibitor in the market, ie finasteride and dutasteride.

Alpha blockers have been shown to improve erectile function. Those with worse erectile function had better improvement with alpha blockers.

However, not all the alpha blocker drugs have similar effects on ejaculation. Alpha blockers that act more specifically on the prostate (uroselective), like silodosin, have been shown to have detrimental effects on ejaculation. There is no effect on sexual desire.

The 5α reductase inhibitors act by inhibiting the conversion of testosterone to dihydrotestosterone.

Dihydrotestosterone is the potent hormone that causes growth of the prostate. It is also commonly known as the male hormone responsible for male characteristics.

Therefore, it is no surprise that 5α reductase inhibitors are associated with a decrease in sexual desire and erectile dysfunction. It is also detrimental to ejaculatory function as well.

However, these sexual dysfunctions are seen mainly during the first year of treatment. The incidence of these problems decreases with longer duration of therapy.

Sometimes, both the alpha blockers and 5α reductase inhibitors are used in combination to treat BPH.

Although symptoms of BPH show better improvement with combination therapy, the incidence of sexual dysfunction increases as well. In fact, the incidence of sexual dysfunction is much worse compared to using either medication alone.

What about surgical treatment?

The gold standard for treatment of BPH is still transurethral resection of the prostate (TURP).

The evidence for sexual dysfunction after TURP is debatable. There are studies which show that it worsens sexual function, but conversely, there are also other studies that show otherwise.

However, what is consistent is the evidence that minimally-invasive treatment of BPH like transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA), is less detrimental to sexual function compared to TURP.

Unfortunately, the long-term success rate for treatment of BPH symptoms with these minimally-invasive therapies are not well established, and may be lower than TURP.

Restoring sexual ability

All is not lost if sexual dysfunction occurs as a result of BPH or its treatment.

If erectile dysfunction occurs, phosphodiestaerase-5 inhibitor medications like vardenafil, tadalafil and sildenafil, can be used.

However, there is a higher risk of postural hypotension (drop in blood pressure) when it is taken together with alpha blockers.

In this situation, the alpha blocker used should be a more uroselective drug (like tamsulosin), which has less complications of hypotension.

Other treatments include intracavernosal prostaglandin injections (injecting a medication known as prostaglandin into the penis), vacuum pump devices, as well as penile prostheses (implanting a medical device into the penis).

If ejaculation is a problem, the alpha blocker can be switched to one that has been proven to have less ejaculatory side effects (like alfuzosin).

There are also other modalities of treatment. However, all these problems are best managed by urologists.

BPH may cause sex-related problems. Similarly, its treatment may also cause sexual dysfunction.

There are treatments available to help alleviate these sexual problems. Consultation with a urologist would be the best step to take.

References:

1. Braun MH, Sommer F, Haupt G, Mathers MJ, Reifenrath B, Engelmann UH. Lower urinary tract symptoms and erectile dysfunction: co-morbidity or typical ‘Aging Male’ symptoms? Results of the ‘Cologne Male Survey’. Eur Urol 2003; 44: 588–94.

2. Rosen R, Altwein J, Boyle P et al. Lower urinary tract symptoms and male sexual dysfunction: the Multinational Survey of the Aging Male (MSAM-7). Eur Urol 2003; 44: 637–49.

3. Mirone V, Sessa A, Giuliano F, Berges R, Kirby M, Moncada I. Current benign prostatic hyperplasia treatment: impact on sexual function and management of related sexual adverse events. Int J Clin Pract. 2011;65(9):1005-13

4. AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;170:530-47.

5. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 2002; 167: 999–1003

6. Jadaine M et al. Effect of TURP on Erectile Function: A Prospective Comparative Study. Int J Impot Res 2010; 22: 146-51

7. Mishriki SF et al. TURP and sex: patient and partner prospective 12 years follow up study. BJU Int 2011; 109: 745-50

8. Hoffman RM, Monga M, Elliot SP, Macdonald R, Wilt TJ. Microwave thermotherapy for benign prostatic hyperplasia. Cochrane Database Syst Rev 2007; CD004135

9. Bouza C, López T, Magro A, Navalpotro L, Amate JM. Systematic review and meta-analysis of transurethral needle ablation in symptomatic benign prostatic hyperplasia. BMC Urol 2006; 6: 14

The male ‘walnut’

AGE WELLm
By Dr CHRISTOPHER C.K. HO

The prostate is a walnut-sized organ in males that can undergo abnormal changes with advancing age.

THE prostate is a walnut-sized gland found only in men, which is positioned below the bladder and in front of the rectum. It forms a ring around the urethra, the passageway that carries urine out of the body from the bladder.

Prostate cancer is a disease where normal prostate cells undergo changes, and these abnormal cells grow out of control. It is more commonly observed in the West. In Malaysia, prostate cancer is the fourth most common cancer among men.

Risk factors

The risk of prostate cancer increases with age. It is rarely found in men younger than 50 years old. Those of African-American background are also at higher risk of having prostate cancer. Men with a first-degree relative (father or brother) who has prostate cancer, is also at a higher risk of getting prostate cancer.

A diet high in animal fat or low in vegetables may also increase the risk of prostate cancer.

Prostate cancer may present as blood in the urine or semen, needing to urinate more often than usual, urine flow that is slower than normal, and erect ion difficulty.

Most of the time, there are no symptoms. However, prostate cancer can present as blood in the urine or semen, needing to urinate more often than usual, urine flow that is slower than normal, and erection difficulty.

Please note that other conditions, like benign prostatic hyperplasia (non-cancerous enlargement of prostate), infection, and bladder stones can cause these symptoms as well.

Diagnosis

If the doctor suspects prostate cancer, he/she will first perform a digital rectal examination by inserting a finger into the anus to feel the prostate. Since the prostate is in front of the rectum, the prostate can easily be felt by pressing the finger on the rectal wall. The surface of the prostate cancer will usually feel irregular and hard.

The doctor will also order a blood test called PSA, which stands for prostate specific antigen. If the level of PSA in the blood is high, there is a high chance that there may be cancer in the prostate.

However, there are other conditions which may falsely cause a high PSA, and this includes urinary tract infection, inflammation of the prostate (prostatitis), benign prostatic hyperplasia, trauma, and sexual activity. Therefore, the doctor may prescribe antibiotics before repeating the PSA test.

It is also advisable to refrain from riding a bike or ejaculating 48 hours before getting a PSA test. If the PSA remains high, a prostate biopsy is recommended.

A prostate biopsy involves using an ultrasound probe which is inserted into the rectum to visualise the prostate. A needle is then used to take prostate tissue samples via the rectum. The number of biopsy samples needed will depend on the man’s age and prostate size. Between six to 12 biopsies are usually taken.

This procedure is not without its complications, namely bleeding, infection, and blood in the urine and semen. A prostate biopsy will be able to confirm the cancer, but a negative test does not rule it out. There is a possibility that the biopsy missed the area which contained the cancer.

In this case, a saturation biopsy where 20 to 30 biopsy samples are taken, may be needed.

Screening

Screening means carrying out tests to detect cancer. For the prostate, it involves performing a digital rectal examination and PSA test.

A large European study has shown that men who had PSA testing had a 20% lower chance of dying from cancer after nine years compared to those without screening. In addition, men with cancers detected by PSA screening have earlier-stage cancer compared to those without screening.

However, most of these early stage cancers detected via screening are unlikely to cause death or disability. Therefore, a number of men will be diagnosed with cancer and potentially suffer the side effects of treatment for cancers that would never have been found without prostate cancer screening.

Indeed, if cancer is detected early, it is not clear in all cases that it must be treated. The European study actually showed only one man in every 1,400 screened benefited from PSA screening. About 75% of men with abnormal PSA who proceeded to have a prostate biopsy, did not have any cancer.

Therefore, should you have a prostate cancer screening? You should discuss this with your doctor. It is advisable if you are symptomatic and have the risk factors, as discussed earlier.

A course of antibiotics will be given before and after the procedure to reduce the risk of infection. Local anaesthesia, either with injection, or gel through the rectum, will be administered.

The whole procedure may take about 15 minutes. The tissue biopsy will then be examined by a pathologist.

The stage of the cancer is based upon how far the tumour extends from the prostate to the surrounding tissue, whether the lymph nodes are involved, and whether the cancer has spread to other organs like the bone.

Magnetic resonance imaging (MRI), computerised tomography (CT) scan, and a bone scan may be needed to stage the cancer.

Stage I and II are localised cancers, stage III locally advanced, and stage IV advanced or metastatic cancer.

In addition to that, doctors also look at the PSA and Gleason grade (based on how the tumour looks under the microscope) to determine how aggressive the tumour is.

Treatment

Treatment will depend on the stage, age, and overall health of the man. When it is at an advanced or metastatic stage, it is not curable. The aim of treatment would then be to control the cancer for prolonged periods of time, reduce symptoms, and improve quality of life.

The options of treatment include watchful waiting, active surveillance, radical prostatectomy, radiation, and androgen deprivation therapy.

In watchful waiting, treatment is deferred until symptoms occur. It is reserved for those with localised prostate cancers and a limited life expectancy, or for older patients with less aggressive cancers.

The rationale is that most cancers detected early rarely cause problems, and instituting treatment has its side effects and may reduce quality of life.

Active surveillance entails more aggressive monitoring and instituting treatment when there is progression of the cancer.

Radical prostatectomy removes the prostate gland and reconnects the urethra and bladder. It can be done via open surgery, laparoscope (placing instruments and a small camera via small incisions), and robot-assisted.

In robot-assisted prostatectomy, the machine performs the surgery via small incisions, under the control of the surgeon from a console. In Malaysia, it is currently available in Kuala Lumpur Hospital, Kuching Hospital, and Prince Court Medical Centre.

Radiation therapy can be either external beam or brachytherapy. External beam radiation uses a machine that moves around you, directing x-rays at the pelvis to kill off the cancer cells.

Brachytherapy involves placing a radioactive source directly into the prostate.

Androgen deprivation therapy decreases the level of androgen hormones (most commonly, testosterone) that fuels the growth of prostate cancer. It can be done via surgery to remove the testicles (orchidectomy) or medicines that interfere with androgens.

If all these fail, the next option is chemotherapy.

The newer approach to treating advanced prostate cancer uses cancer vaccine. This immunotherapy involves isolating the white blood cells (dendritic cells) from the patient’s blood, stimulating them outside the body with various chemicals to build the body’s immunity against the cancer, and then reinjecting them back into the patient’s body. These dendritic cells will then mount an immune response against the cancer cells.

Vitamin E and selenium were previously thought to be able to reduce the risk of prostate cancer, but studies done have proven otherwise.

Finasteride and dutasteride have been shown to reduce the risk of developing prostate cancer by about 25%, but it must be weighed against the cost and potential side effects of these medications when taken long-term.

So, if you have risk factors for developing prostate cancer, discuss with your doctor about screening for it. Treatment depends on a lot of factors. Therefore, a discussion with the doctor will result in the best treatment option.

Faster than a speeding bullet

By Dr CHRISTOPHER HO CHEE KONG

Premature ejaculation is defined as ejaculating within one minute of vaginal penetration.

A COMMONLY misunderstood condition which frustrates men is premature ejaculation (PE).

What is PE? It is the act of ejaculating before a man or his partner would like to.

Epidemiological studies have shown that this disease afflicts men of all nations equally. It is also a disease that affects men across all ages.

About a third of men often complain of this problem, but the actual figure is about 1-3%. PE has long been a condition that has been under-reported and under-diagnosed, mainly because of the embarrassment faced by sufferers, who have to put up with the social stigma related to the condition.

The Asia-Pacific Premature Ejaculation Prevalence and Attitude Study carried out among more than 5,000 heterosexual men found that most men are reluctant to talk about it, while the majority of couples do not completely understand the condition.

The International Society of Sexual Medicine defines PE as ejaculating within one minute of vaginal penetration, associated with the inability to delay ejaculation, and causing a negative impact on the man.

Why one minute? Studies have shown that the average time to achieve ejaculation in a man is about five minutes. Among men who complained of premature ejaculation, 90% stated it was less than a minute.

So how do doctors diagnose this problem? By getting a good history. If a man is distressed because he ejaculates early (about a minute) and he has no control over it, he would probably need treatment.

There is a questionnaire called the Premature Ejaculation Diagnostic Tool (PEDT) that may aid in the diagnosis. Other than that, there is no special equipment or test that can be used to diagnose this problem.

Previously, PE was thought to be a psychological disorder. We now know this is not entirely true. It has been shown to have a neuro-biological cause as well (organic).

Certain neuro-transmitters (biochemical substances that transmit impulses across nerves) like serotonin are involved in the process of ejaculation. Ejaculation is a complex process involving the interplay of many factors that are not completely understood.

PE may occur in a man who has had normal ejaculation before. This is known as acquired PE. In this situation, it may be due to a psychological problem rather than an organic cause.

On the other hand, if a man has never had normal ejaculation before, he probably has a neuro-biological cause for it. This is also known as lifelong PE.

Hyperthyroidism (a disease where the thyroid hormones are elevated) and prostatitis (inflammation of the prostate gland) may also cause premature ejaculation.

Treating PE should not focus solely on prolonging the ejaculation time. It is important that proper attention is given to the emotional and relationship factors as well. PE may be treated by sex therapy, medication, or a combination of both.

Sex therapy

This involves education about ejaculation, an exploration of how the affected man’s PE experience compares with that of most other men, and a programme of exercises (this includes the “stop-start” and “sensate focus” technique) designed to help him increase his ejaculatory control and enjoyment of sexual intimacy.

It is usually carried out by a trained psychologist or psychiatrist.

Medications

Selective Serotonin Reuptake Inhibitors (SSRI) – These drugs manipulate the serotonin pathway, and in a way, increase the threshold of sexual climax and ejaculation.

The conventional SSRIs like paroxetine and sertraline are traditionally used to treat depression, but have been found to be effective for PE. The only problem is the associated side effects like drowsiness, constipation and nausea.

Moreover, conventional SSRIs need to be taken for at least two weeks before the beneficial effects could be seen. Stopping the conventional SSRIs also need to be done gradually over a few days.

To overcome all these problems, a new SSRI drug is currently available in the market. It is known as dapoxetine. It is a short-acting drug that can be taken on-demand.

In other words, dapoxetine can be taken only when it is needed (ie one to two hours before sex). Side effects of dapoxetine are also uncommon. It has been proven in studies to be effective in increasing ejaculatory time as well as satisfaction of the couple involved.

Topical anaesthetics – Lidocaine and prilocaine cream can be used to reduce the sensitivity and sensation of the penis. It has been proven to be effective, but the problem is it may cause total numbness of the penis. This will diminish the pleasure derived from sex.

In addition to that, the cream may be transferred to the partner and cause numbness to the partner as well.

Tramadol – Studies have also proven the effectiveness of tramadol to delay ejaculation.

Tramadol is a drug that is usually used to reduce pain. How it works in delaying ejaculation is not completely understood.

However, the drawbacks are side effects like nausea, vomiting and drowsiness.

It is also important to look out for concommitant erectile dysfunction (inability to maintain satisfactory erection of the penis for penetration) as treatment of erectile dysfunction with phosphodiesterase-5 inhibitors (like sildenafil, vardenafil and tadalafil) may overcome the problem of premature ejaculation as well.

PE is a man’s disease, but it affects both the man and his partner. Treatment is available and the combination of both medication as well as psychological sexual therapy may help.

Consultation with a urologist or psychiatrist would be needed.

References:

1. International Society for Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation.http://www.issm.info/images/uploads/PE_Guidelines.pdf.

I am man

AGE WELL
By Assoc Prof Dr CHRISTOPHER C.K. HO

All about testosterone and sexuality in men.

TESTOSTERONE is a hormone produced naturally in the body. In men, it comes mainly from the testis. The adrenal glands also produce small amounts of testosterone.

Many do not know this but testosterone is not exclusively a male hormone. Testosterone is also produced in women, mainly in the ovaries, but the amount of testosterone is much lower as compared to men.

Testosterone causes increased muscle bulk as well as the growth of bones. In men, it helps in the development of male sex organs (penis and prostate). The deepening of the voice in men as well as growth of beard is also caused by testosterone.

Testosterone Deficiency Syndrome

When testosterone levels in the body drops below normal (less than 12 nmol/l), symptoms like lethargy, mood disturbance, irritability, loss of muscle mass, depression, loss of concentration and obesity (increased waist circumference) may occur.

This is known as testosterone deficiency syndrome (TDS). Other names for it include hypogonadism, andropause, androgen deficiency in ageing males (ADAM) and partial androgen deficiency in ageing males (PADAM).

The rate of decline of testosterone levels in the body is about 1% annually after the age of 30.

Testosterone deficiency may also give rise to sexual issues like loss of interest in sex, decreased arousal, low desire, low libido, erectile dysfunction and infertility in men.

This will inadvertently reduce quality of life.

Treatment of TDS

The deficiency of testosterone in the body can be addressed by synthetic testosterone. There are many different preparations of testosterone. It can be swallowed as pills (oral tablets), be injected into the muscle (intramuscular) or fat (subcutaneous pellets), applied to the gums (buccal tablet), and applied on the skin as gels or patch.

The intramuscular injections as well as gel preparations are more commonly used worldwide.

Studies have shown conclusively that for men with low testosterone levels, when they are given testosterone supplementation, quality of life improves as the testosterone levels pick up to the normal range.

The change can be quite dramatic; there is increased energy, increased muscular tone and improved mood. There is also better control of the cholesterol and sugar levels in the blood.

Effects of testosterone on sexuality

When a man falls in love, his testosterone level decreases, but the opposite is true for a woman.

Men producing less testosterone are more likely to be in a relationship and/or married, and men producing more testosterone are more likely to divorce.

Men producing more testosterone are also more likely to engage in extramarital sex.

Higher levels of testosterone are associated with periods of sexual activity within subjects. Men who have sexual encounters with unfamiliar or multiple partners experience large increases of testosterone the morning after.

When testosterone is given to men who have testosterone deficiency syndrome (TDS), it has been shown that their sexuality improves.

The enhancement of the mood and energy levels, boosted by the change in body image (as there is less body fat, decreased waist circumference and more muscle tone) will further restore their virility.

Studies done in men have proven that testosterone improves sexual drive, desire and arousal.

Similarly, the quality of erection is also much improved when testosterone is administered to those with TDS.

These changes can be seen as early as three weeks, though for quality of erection, it may only be noticed after six months.

The effect of testosterone on sexuality in women is still controversial and much debated.

Synthetic testosterone administration is not without its side effects. It may cause acne, virilisation (excessive hair growing on all parts of the body), excessive increase in the red blood cells and worsening of sleep apnoea (a sleep disorder that results in frequent night time awakenings and daytime sleepiness), among others.

Administration of synthetic testosterone may also cause the testes to shrink. This in turn will cause decreased production of sperm and may result in infertility.

Treatment of infertile men with TDS

Men who plan to start a family but have low levels of testosterone are generally not advised to take testosterone. There are other options to increase their testosterone levels without compromising their fertility.

These include gonadotropin releasing hormone (GnRH), human chorionic gonadotropin (hCG), human menopausal gonadotropin (hMG), follicle stimulating hormone (FSH), anti-oestrogens (like clomiphene) and aromatase inhibitors.

Two herbal medications that have undergone trials to test their effects on infertile hypogonadal men are Withania somnifera and Mucuna.

If a man is already on testosterone supplements, most studies have shown that sperm production may return to normal within a year if it is discontinued.

If all fails, the last option is artificial reproductive techniques, which include extraction of a single sperm from the testis of the father and injecting it directly into the egg (oocyte) of the mother. This happens outside of the body. When the oocyte is successfully fertilised, it is then re-implanted into the womb (uterus) of the mother.

Testosterone and sexuality in men are inter-related.

Replacement of testosterone in men with testosterone deficiency syndrome may overcome sexual dysfunction issues.

However, those who plan to start a family should refrain from using synthetic testosterone preparations. Other options are available to increase testosterone naturally in the body.