Cystoscopy

Cystoscopy is done to examine and diagnose disorders of the urinary bladder and urinary tract. In this procedure, the internal structure of the urinary bladder and the urinary tract can be examined by using the cystoscope. Cystoscopes are administered as both diagnostic and treatment tools. Cystoscopy is predominantly done for patients experiencing recurrent urinary tract or bladder infection, urinary incontinence, hematuria and pain because of obstruction in the urinary tract. The procedure is performed by a urologist by inserting a tube called cystoscope through the urethra to identify disorder.

Cystoscopy Procedure

The duration of the procedure depends upon the condition of the patient. The procedure usually lasts about 45 minutes and it is performed under local, spinal or general anesthesia. Pathological specimens of the urinary bladder can also be obtained by using cystoscopes. Patients are advised to abstain from taking food or water six hours prior to the procedure. In case of rigid cystoscopy, the inserted cystoscope is used to remove any kind of lesions present in the urinary tract or the bladder. In the flexible cystoscopy procedure, the internal lining of the urinary bladder and the urinary tract are examined for abnormalities.

With cystoscopy, small bladder stones or foreign objects can be removed; thereby eliminating surgical intervention. Cystoscopy is useful in examining enlarged prostate, kidney stones and urethral blockage. This procedure is used to place urethral catheters or stents.

Complications of Cystoscopy

The complications associated with the cystoscopy procedure are mostly due to a perforation in the urinary tract. These perforations are caused during the procedure and might lead to urinary tract infection and bleeding. In men epididymitis occurs if testicles are involved during the procedure. The other complications include difficulty in passing urine and abdominal pain. In order to avoid the onset of urinary tract infection after the procedure patients are advised to take fluids preferably water every hour.

DSD

After childbirth, the usual and much awaited announcement from a midwife in the labor ward is - 'it's a boy' or 'it's a girl'. But there are instances when the midwife cannot determine the sex of the baby as the sex organs do not conform to defined norms of a male or a female. The baby is born with sex organs that aren't clearly male or female. There is ambiguity about the gender. The child is born with a disorder of sex development (DSD). In all probability the midwife may relate to the newborn as 'baby'. Here is a child diagnosed with DSD at birth.

An estimated 2,000 babies are born 'intersex' each year, referring to a set of over 60 different conditions that fall under the diagnosis of 'DSD' (Differences/Disorders of Sex Development). DSD occurs more often than Down syndrome or cystic fibrosis. In the last 15 years, there is more openness about DSD which has led to moving beyond the medical/biological realm. There is growing interest in gender studies as well.

From Intersex syndrome to DSD

Other terms in place of disorder of sex development are 'intersex' (between the sexes) or 'hermaphrodite' or 'pseudohermaphroditism'. International experts held a conference (International Consensus Conference on Intersex) in 2006 and have reached a consensus that the term DSD or disorder of sex development should replace all those terms.

Some people prefer to use terms like 'differences in sex development' or 'diversity of sex development'. There are three basic types of DSDs. These manifest in different ways. Understanding X and Y chromosomes can help in sorting out the types of DSDs.

Females have two X chromosomes (XX) in each cell. This is by inheriting one X chromosome from each parent. Two X chromosomes is medically written as Karyotype 46, XX. And males have an X chromosome and a Y chromosome (XY). This is by inheriting an X chromosome from the mother and a Y chromosome from the father. An XY is referred to as Karyotype 46, XY.

The Y chromosome helps make a boy as it contains the genes for the development of male organs like the testes and penis. This happens around the 6th week of fetal development. As the testes make testosterone, the penis, scrotum and urethra form. Between 7th and 8th month of the pregnancy, the testes descend into the scrotum. In the absence of the Y chromosome, the fetal tissue in a female fetus (XX) will form the female sex organs – the ovaries, uterus and the fallopian tubes.

Causes of disorder of Sex development

Through the many stages of sex development, if all is typical the fetus develops into a normal male or a female. But, if at any stage of sex development an atypical development takes place it results in a 'disorder of sex development. Like:

• Influence of chromosome variations result in genetic disorders
  
  
• Congenital issues (that are present at birth)
  
  
• Genetic change that may or may not be inherited from a parent
  
  
• Unknown exposure to certain medications or hormones during pregnancy
  
  
• Problem during the development stage that prevents the production of enough hormones due to lack of blood flow to the ovaries or testes.
  

Types of DSDs

• Sex chromosome DSD
  
  
• 46, XY DSD
  
  
• 46,XX DSD
  

Diagnostic approach to DSD

Diagnosis begins with determining the type of disorder of sex development. Physical examination, medical history of the mother's health during pregnancy and family history of any neo-natal deaths form part of the diagnosis. A biopsy of the reproductive organs is done where necessary.

• Blood tests to check DNA and hormone levels
  
  
• MRI to study internal structures like gonads
  
  
• Ultrasound or direct Cystoscopy or vaginoscopy to take images of internal gonads.
  
  
• MRI or CT, and a retrograde genitogram to assess the Müllerian structures and the kidneys.
  
  
• Genital Urethrogram to look at the urethra and vagina, if present
  
  
• Chromosomal analysis to determine the genetic sex (46 XX or 46 XY)
  
  
• SRY Gene evaluation: An essential protein for sex termination in human males found on the Y chromosome. Also known as sex-determining region on Y, sex determining region protein, SRY_HUMAN, TDF, TDY or testis determining factor.
  
  
• Endoscopy, laparoscopy and gonadal biopsy
  
  
• Electrolyte tests such as sodium, potassium and glucose levels
  
  
• Fertility test
  
  
• Test to determine size and potential for growth of the penis in an undersized male pseudohermaphrodite
  
  
• Test to analyze the ability of an internal reproductive organ to produce sex hormones for the gender chosen
  
  
• Test to check possibility of future health conditions that may develop in the original reproductive organs
  
  
• Test to determine the action of male or female hormones on the fetal brain.
  

Treatment of DSD

Treatment options are based on specific diagnosis and issues involved. Not restricted to medical treatment, it involves psychological support as well. Reconstructing external genitalia or removing internal genitalia are surgical procedures. In some cases, more than one surgery is needed.

• Diagnostic evaluation, including examination, blood tests such as chromosome analysis and other genetic testing, and imaging (X-ray, ultrasound, MRI)
  
  
• Psychosocial support
  
  
• Genetic counseling
  
  
• Medical management, including hormone treatment (hormone replacement and hormone suppression)
  
  
• Surgical procedures when indicated
  

Surgical procedures for DSD

Not every DSD requires surgery. Medications may also be used to treat certain DSDs. Experts recommend waiting till adolescence to understand the individual's preference for identity. In children, surgery is necessary:

• For a child born without an opening for urination and to remove risks of complication, a surgery for opening is essential.
  
  
• A surgery to obtain a sample of the gonad to determine whether ovarian and/or testicular tissue, a biopsy and surgery is required.
  
  
• A surgery to reduce the size of a large clitoris or surgery to remove a gonad that is at risk to develop cancer is important.
  

Feminizing surgery: Going by 'Chicago Consensus', Feminizing surgery should only be considered in cases of severe virilisation. Also, the emphasis should be on functional outcome rather than cosmetic appearance. An ongoing debate on Feminizing Surgery is the timing of the surgery. A section believes in performing early feminizing surgery. Yet another section advocate feminizing surgery in adolescence as the patient is involved in discussions and decision-making.

• Clitoroplasty: Reduce the size of the clitoris
  
  
• Labioplasty: surgical modification of the labia
  
  
• Vaginoplasty: to create a vagina or enlarge an existing one.
  

Enlarged Prostate

Prostate gland enlargement is common in men as they grow older. For men above 50, the most common prostate problem is prostate enlargement. 50% of men by age 60 suffer from this problem and over 90% of men suffer from this problem when they are 80 plus. Enlarged prostate is also known as prostatic hypertrophy, benign prostatic Hyperplasia or prostate gland enlargement.

Enlarged prostate is a benign enlargement and is non- cancerous. This condition often induces urinary problems. If left untreated, the problem can block the flow of urine out of the bladder and cause urinary infection, kidney and bladder problems. The prostate gland is located beneath the bladder; this tube passes through the center of the prostate and transports urine from and out of the penis. Therefore when the prostate is enlarged, it obstructs the flow of urine. With time, the bladder muscles thicken severely and become over sensitive thus forcing the person to urinate frequently as the bladder can't hold even small amount of urine.

Symptoms of prostate gland enlargement

• Increased frequency of urination at night.
  
• Unable to empty the bladder completely
  
• Urinary tract infection
  
• Reduced kidney function
  
• Frequent or urgent need to urinate
  
• Weak urine stream
  
• Strain to urinate
  
• Bladder stone
  
• Difficult to start, stop and restart urination.

Diagnosis includes:

Physical examination and understanding the patient's medical history.
Rectal examination to identify if the prostate is enlarged.
Urine tests.
Urine flow test.
PSA (Prostate Specific Antigen) test in blood.
Trans rectal ultrasound to measure prostate.
Neurological examination to identify reasons other than prostate enlargement for urinary incontinence etc.
Post void residual volume test, to identify if the patient can empty the bladder completely.
Prostate biopsy.
CT urogram to identify blocks in urinary bladder.
Cystoscopy to check bladder and urethra.